Federally-Facilitated Marketplace (Ffm) User Fee Adjustment Web Form Quick Startguide - Centers For Medicare And Medicaid Services Page 11

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FFM User Fee Adjustment Web Form Quick Start Guide
Figure 10: TPA/PBM Notice of Intent Page
The next step for the TPA or PBM is to report all FFM User Fee Adjustment information for each
self-insured plan for which the TPA or PBM intends to seek an FFM user fee adjustment.
Table 5: TPA/PBM Report of Contraceptive Claims Cost Page
Step
Action
1
Enter the Tax Identification Number.
2
Enter the number of self-insured plans for which the TPA or PBM intends to
seek an FFM user fee adjustment.
3
Select the Create Table button.
Note: The number entered in the “Enter the number of Self-Insured Plans for
which the TPA or PBM intends to seek an adjustment” field will determine how
many rows are created in the FFM User Fee table.
4
In the FFM User Fee table, enter the self-insured plan Tax Identification
Number.
5
In the FFM User Fee table, enter the number of participants and beneficiaries
in self-insured plan administered by the TPA or PBM.
FFM User Fee Adjustment Web Form Quick Start Guide
11

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